Going Solo

Written by: Abbie Ruisch, D.O.

In the spring of last year I was preparing to graduate from the Iowa Lutheran Family Medicine Residency Program. Many people wanted to know my future plans. When I told them I was joining a solo practitioner in Johnston, there were different reactions. They ranged from a look that said, “Are you completely insane?” to slaps on the back and comments like, “Good for you! If I could do it, I would.”

I have to be honest about what led me to where I am today. I’m generally a rule-follower. I like structure and guidelines in my life. I’m independent, but not bull-headed. Had my residency class voted, I would have been “Least Likely to go into Solo Practice.” I simply had no other option at the time. A year and a half ago when I began looking for a job in Des Moines, I heard over and over, “no one’s hiring right now.” I was frustrated and concerned. 

As a Des Moines native, my plan from the beginning was to stay in or around the Des Moines area to set up my practice. My family is here. My husband has a great job here. This is a terrific place to raise a family. When a friend of the family came to me in the late summer of 2003 and said his physician was looking for a partner and would I like his e-mail address, I jumped at the chance to explore this possibility.

I e-mailed Dr. Robert Lee a few days later, half expecting to get no response. He surprised me by e-mailing promptly back and telling me about himself and what his goals were for the near future.  He was a solo practitioner located in Clive but looking to move into the Urbandale/Johnston area with a partner to share expenses and call. I was interested, and we met a few times with our spouses over dinner. Our personalities seemed to compliment each other. 

Financial

We discussed the many financial issues surrounding a partnership. My husband and I poured over the numbers. I should say my husband (an accountant) poured over the numbers and explained them to me. We concluded that it was a risk financially, but likely worth the risk in the long run. As we looked at what my potential earnings could one day be, we were impressed. I was going to have to sacrifice in the beginning, but the pay-off looked to be incredible. Dr. Lee agreed to float me until I was up and running enough to pay him for half of the expenses he had incurred in going solo as well as salaries for our nurse, office manager, and secretary. 

Reality sets in

I started at my brand new office with my brand new desk and chair that squeaks on August 2, 2004. My diplomas were neatly framed and hung on the wall. I bought artwork for my exam rooms. I passed my board exams. Everything was ready for the patients to flood through my door. Needless to say, it was more like a trickle. Some days, it was a drought. I was putting in my time at the office with nothing to show for it. I had no signing bonus, no guaranteed salary for the first 2 years. To top it off, a month into it my husband and I found out we were expecting our second child in May. We were elated (yes, it was planned that way), but the pregnancy shot the pressure to become profitable through the roof. 

I spent my days seeing patients here and there while learning to be a businesswoman and advertiser rolled into one. I quickly realized that I was not trained for this. Nor did I enjoy the thought of having to “sell” myself. I just wanted to practice medicine and have a nice life. I unenthusiastically began the process of promoting myself in the community around me. I brought fliers and business cards to local businesses. I mailed brochures to new residents in the area. My partner and I advertised in the Des Moines Register. I called club after club and school after school offering to do talks for them with few takers. I joined the Johnston Chamber of Commerce and started going to the monthly luncheons. I joined the board of an organization in Johnston called Partnership for a Healthy Community. 

The first five months of practice were difficult. My patient visits were not increasing and I wondered what I had gotten myself into. I continued to persist, however, and have recently begun to reap the benefits of those early months. In January, I received several phone calls from people who wanted me to speak at various community events and write articles for this or that publication. I was making some new connections through my involvement in the Chamber as well as the Partnership organization. I even found myself enjoying these things, much to my surprise. My patient load began to show an increase—a slow one, but a definite increase.

Disadvantages

There are certainly disadvantages to solo practice. Not the least of which is the financial burden in starting one up. I was fortunate to join a practitioner who had done all of the hardest work—finding a location, financing it, hiring good employees, and selecting and learning to use an Electronic Medical Record system. He also already had a patient base from which I could benefit.  For me, the biggest challenge has been learning to start a practice from scratch with no financial benefit to tide me over until I become profitable.

Advantages

What I like about solo practice is the autonomy I experience.  As a fresh-faced new doctor, I am involved in all decision-making that goes on in my clinic and there is no one to answer to. That has been a hard role for me to take on, but one I am increasingly enjoying. My partner and I have to agree on things, but beyond that, there are no committees to send issues through. We don’t have to convene a meeting to discuss vacation, schedule changes, or “quality improvement” issues. My partner and I are where the buck stops.

My family is important to me. I’ve never wanted to end up with a 60 hour work week, seeing 40 patients per day while also working occasional nights, weekends and holidays. I want to spend time with my husband and kids. I don’t want to wake up when I’m 50 years old and feel as though I missed this critical time with them. Call me selfish, but I love that I can work whatever hours I want without guilt from anyone telling me I should work more. The times I spend on and off the job are up to me.

Our patients notice a difference with us as well. They like knowing the staff by their first names and being recognized when they walk in the door. They also know that if something isn’t right, we aren’t going to ask them to fill out an incident report or call an office manager to make it right. We fix the problem immediately. If they call about a difficulty with their bill, they don’t get shuffled off to a corporate office to explain the problem to six different people who don’t know them and who blame the insurance company. They speak to our office manager who does all of the coding, billing, posting and dealing with insurance companies for us. If it’s a problem on our end, we accept responsibility for it. They also get appointments when they need them, not a week later. We give great customer service in our office. I’ve had many patients comment that they like feeling like a person, not just a number, when they come to see me. They especially like the amount of time I spend with them.   

We are also very cost-conscious. Now that I’m paying for them, it matters to me what supplies cost and where we get them. Our nurse does a great job of checking out prices from various vendors to get the best deal. I also think I’m becoming good at distinguishing what tests I really need verses what I’m ordering out of habit. We have limited lab and no x-ray, so I have to be discerning about what I order. I think that leads to better patient care and avoids a “shotgun” approach to medicine. I get what I need and nothing more.  

Call 

I take my own patient call 24/7. My patients are given my cell phone number on our answering machine after hours. They don’t abuse it, because they know they are interrupting dinner with my family or my sleep when they call. In fact, they usually apologize profusely for calling me. I can count on one hand the number of inappropriate phone calls I’ve received since I started. That includes the times I’ve covered the entire clinic when Dr. Lee is out of town. Patients are amazed that we are so available to them by phone. They also enjoy the fact that they don’t get another doctor who doesn’t know them when they call. With my EMR, I can also access their records from my home.

In Conclusion

Over everything else, my favorite part about my practice is the family atmosphere we experience in our clinic. I get to spend lunches getting to know my staff and partner. We all get along well and genuinely care about what is going on in each other’s lives. I like it that we have an open-door policy and my staff doesn’t feel uncomfortable asking me questions or telling me if something isn’t going well in the office. I think everyone feels appreciated—from the nurse to the office manager to my patients. It inspires loyalty from all because we know that we are a team. That is what it’s all about. Going solo probably isn’t for everyone, but it’s working for me.